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Current Health Insurance:
Cigarette / E-Cigarette User?
Yes
No
Dependents to Enroll
Spouse
Child 1
Child 2
Dependents to Enroll
Child 3
Child 4
Child 5
Spouse First Name
Spouse Last Name
Spouse Date of Birth
Cigarette / E-Cigarette User?
Yes
No
[{"field":"{dependents1}","logic":"contains","value":"Spouse","and_method":"","field_and":"","logic_and":"","value_and":""}]
Child 1 First Name
Child 1 Last Name
Child 1 Date of Birth
Cigarette / E-Cigarette User?
Yes
No
[{"field":"{dependents1}","logic":"contains","value":"Child 1","and_method":"","field_and":"","logic_and":"","value_and":""}]
Child 2 First Name
Child 2 Last Name
Child 2 Date of Birth
Cigarette / E-Cigarette User?
Yes
No
[{"field":"{dependents1}","logic":"contains","value":"Child 2","and_method":"","field_and":"","logic_and":"","value_and":""}]
Child 3 First Name
Child 3 Last Name
Child 3 Date of Birth
Cigarette / E-Cigarette User?
Yes
No
[{"field":"{dependents2}","logic":"contains","value":"Child 3","and_method":"","field_and":"","logic_and":"","value_and":""}]
Child 4 First Name
Child 4 Last Name
Child 4 Date of Birth
Cigarette / E-Cigarette User?
Yes
No
[{"field":"{dependents2}","logic":"contains","value":"Child 4","and_method":"","field_and":"","logic_and":"","value_and":""}]
Child 5 First Name
Child 5 Last Name
Child 5 Date of Birth
Cigarette / E-Cigarette User?
Yes
No
[{"field":"{dependents2}","logic":"contains","value":"Child 5","and_method":"","field_and":"","logic_and":"","value_and":""}]
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